At Alberta Blue Cross®, we’re embracing AI technology to help fight fraud.

According to Naz Tahmasebi, manager of Analytics and Reporting, AI is growing exponentially each day. With its ability to analyze vast amounts of data, identify anomalies and make decisions faster, AI has the power to transform the fraud detection process.

“AI has the unlimited potential to transform most industries. It is getting stronger and more sophisticated and presents revolutionary possibilities,” she says.

Tahmasebi has written a white paper on the topic . We break down some of her main points below.

Understanding machine learning

Fraud and the people who commit it are constantly evolving. This means we tend to rely more on machine learning than traditional programming to raise the red flag.

  • Traditional programming is a rule-based approach. The programmer accounts for each step required to solve a problem or complete a task.
  • Machine learning, on the other hand, is inspired by how humans learn—the programmer feeds data to the algorithm and lets the machine figure out how to solve the problem by itself.

“What’s amazing about machine learning in the area of fraud detection is its capacity to learn and adapt, continually refining its understanding of normal and abnormal behaviors,” explains Tahmasebi.

Machine learning helps identify anomalies, patterns and suspicious activities that indicate potential fraud, which allows for timely intervention and prevention.1 By learning from and modelling historical data, machine learning algorithms can identify abnormal and risky activities and apply rules better than human beings and traditional programming can.

Various industries such as banking, insurance, health care and e-commerce use machine learning to detect fraud. “In today’s fast-paced digital landscape, AI and machine learning is the transformative force that is reshaping industries,” Tahmasebi adds.

Keeping costs down

Benefits fraud not only affects the individuals involved, potentially leading to job loss, legal consequences and financial implications—but it also places a collective burden on plan members and employers by impacting premiums.

Our machine learning models, enable us to flag cases that require further investigation. This helps us allocate our resources more efficiently and keep costs down, resulting in improved quality and service for our customers.

 “The strategic use of AI and machine learning empowers Alberta Blue Cross® to not just detect benefits fraud but stay ahead of evolving schemes, ensuring proactive intervention, heightened service quality and cost-effectiveness for our customers,” says Vivianna Botticelli, vice-president and chief audit executive.

At Alberta Blue Cross®, our dedicated team of data scientists use a dynamic and adaptive multi-layered approach that combines AI and machine learning technologies to proactively identify abnormal and suspicious claiming patterns and connections. Read our white paper to learn more about our comprehensive fraud detection system that goes beyond traditional methods.

1 ( Machine learning can identify potential money laundering, claims and credit card fraud, spam emails and cyber security attacks.

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